More Questions on This Topic
More Questions on This Topic ( 10 Questions)
A nurse is caring for a client who has a venous leg ulcer on the lower left calf. The nurse notes that the wound has copious amounts of yellow-green purulent drainage with a foul odor. The periwound skin is erythematous, warm, and edematous. The client reports increased pain and fever. What should the nurse do first?
Compression therapy is indicated for clients with venous leg ulcers to improve venous return and reduce edema, but it is not the first priority in this case. The nurse should first address the infection before applying compression bandages.
Rationale: The nurse should first obtain a wound culture and sensitivity to identify the causative organism and the appropriate antibiotic therapy for the client's wound infection. The nurse should use sterile technique and collect the specimen from the wound bed after cleansing the wound with normal saline.
Administering analgesics and antipyretics may help to relieve the client's pain and fever, but it does not treat the underlying cause of the infection. The nurse should first obtain a wound culture and sensitivity before administering medications.
Elevating the affected leg may help to reduce edema and improve blood flow, but it does not address the infection. The nurse should first obtain a wound culture and sensitivity before elevating the leg.
Correct answer: B) Obtain a wound culture and sensitivity
Rationale: The nurse should first obtain a wound culture and sensitivity to identify the causative organism and the appropriate antibiotic therapy for the client's wound infection. The nurse should use sterile technique and collect the specimen from the wound bed after cleansing the wound with normal saline.
Incorrect options:
A) Apply compression bandages to the affected leg - Compression therapy is indicated for clients with venous leg ulcers to improve venous return and reduce edema, but it is not the first priority in this case. The nurse should first address the infection before applying compression bandages.
C) Administer prescribed analgesics and antipyretics - Administering analgesics and antipyretics may help to relieve the client's pain and fever, but it does not treat the underlying cause of the infection. The nurse should first obtain a wound culture and sensitivity before administering medications.
D) Elevate the affected leg above the level of the heart - Elevating the affected leg may help to reduce edema and improve blood flow, but it does not address the infection. The nurse should first obtain a wound culture and sensitivity before elevating the leg.